A Patient and Healthcare Worker-Informed Approach to Identifying Barriers to and Strategies for Antibiotic Stewardship at the Hospital-to-Home Transition

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Project Abstract Antibiotic resistance is increasing worldwide, largely driven by excessive antibiotic use. Antibiotic stewardship (AS) addresses antibiotic resistance by ensuring that only patients who require antibiotics get them, and that patients receive the right medication at the right time at the right dose for the right duration. AS interventions have typically focused on hospital, long-term care, and ambulatory settings in isolation. However patients also receive antibiotics as they transition from one care setting to another. Discharge antibiotic decision-making remains an important but under-addressed target for AS, and we require a better understanding of how to improve this process. Optimizing AS also requires attention to post-discharge processes. Most components of AS during the hospital-to-home transition are patient led tasks--taking the antibiotic at the right time, at the right dose, and for the right duration—and must occur in a timely way once the patient arrives home. Medication management (MM) refers to the ability to obtain, administer, and take medications according to a prescribed regimen. In our model of MM during the hospital-to-home transition among older adults, we identified healthcare worker-initiated processes and patient and caregiver-initiated processes that must be successfully completed for patients to optimally receive prescribed treatments. However it is unclear how antibiotic MM may fit into a general MM model. To date, no research has integrated discharge antibiotic decision-making with patient-led antibiotic MM as a series of interrelated processes necessary for AS during the hospital-to-home transition. We will use participatory design and multiple methods to actively engage stakeholders in describing discharge antibiotic decision-making and antibiotic MM to identify barriers to and strategies for AS during the hospital-to-home transition. Aim 1: To identify barriers to AS during the hospital-to-home transition in the integrated processes of discharge antibiotic decision-making and patient-led antibiotic MM. Using the Transition Model of MM as the underlying framework, we will interview healthcare team member stakeholders and perform home-based contextual inquiry with semi-structured interviews of patients discharged on antibiotics, about the intertwined processes of discharge antibiotic decision-making and patient-led antibiotic MM. These methods will help us identify barriers to AS during the hospital-to-home transition and develop an integrated process map for AS during the hospital-to-home transition. Aim 2: To complete a proactive risk assessment to identify strategies to mitigate barriers to AS during the hospital-to-home transition. We will present this data to clinicians and patients and caregivers, who will go through a Failure Modes and Effects Analysis (FMEA) risk assessment to develop and prioritize potential strategies for addressing barriers to AS during the hospital-to-home transition. We will use identified barriers, strategies, and the integrated process map to suggest components of a future intervention that optimizes both discharge antibiotic decision-making and antibiotic MM.